Healthcare Provider Details

I. General information

NPI: 1518564715
Provider Name (Legal Business Name): NICOLE MARIE HUTCHINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 S VANDER MEULEN RD
LAKE CITY MI
49651-8717
US

IV. Provider business mailing address

519 S VANDER MEULEN RD
LAKE CITY MI
49651-8717
US

V. Phone/Fax

Practice location:
  • Phone: 231-839-0074
  • Fax: 231-839-0252
Mailing address:
  • Phone: 231-839-0074
  • Fax: 231-839-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: